Morphine's Obsolete

[x635 4,066]

Does anyone else think that Morphine is obsolete??

I've never found Morphine to be a great solution to pain management. With synthetic opitates on the market scuh as Fentanyl, there are much better and more effective alternatives prehospitally.

As far as it's use in MI's, studies have show that morphine actually reduces perfusion pressure, which actually hurts the patient.

Finally, with the advent of CPAP, morphine's no longer need in CHF. CPAP has proven so effective in treating CHF prehospitally, and reduced patient stays, that CPAP machines are being put in the toolbox and morphine taken out. In fact, one of the larger hospitals in Houston, TX donated 62 CPAP machines to equip every FD ambulance with one because it reduces the Pt's need to stay in the hospital, especially ICU. A lot of pt's don't have money, so by buying these CPAP machines for EMS, the hospital actually saved over $3 million dollars last year, and most importantly, improved pt's outcomes.

Has any department removed morphine because of the above, or are trying to?

[STAT213 332]

Seth,

The State of Maine's newest protocol (starting July 2008) has eliminated MS completely from their protocols.

I've seen a couple of the studies you're referring to, and it all sounds legit.

One of the things my paramedic instructor always taught us: Half of what I will teach you is wrong. I just don't know which half. - Richard Cherry

We use mostly Fent up here, but still have MS. We also have CPAP. Good stuff!

Rob

Edited July 14, 2008 by STAT213

[Guest EFFP411]

These days, you don't even need a CPAP machine anymore. They have oxygen powered, self contained, disposable CPAP masks. The only thing you need is a flowmeter that goes up to 25! Its cretainly cheaper than buying a machine. We use them at Mobile Life, and i think its a great tool, and has outstanding results as far as patient care and stabilization is concerned. Unfortunately, i don't have any useful input as far as morphine is concerned....

Edited July 15, 2008 by EFFP411

[Goose 188]

Westchester doesn't have fentanyl in the protocols so how could you remove MS for pain management?

[traumajunky 5]

I love our protocols... first 5mg of MS is free... As for CHF we do not use MS...

PAIN MANAGEMENT

CRITERIA

• Pain (>4 out of 10) due to burns, amputation, or isolated extremity fracture / dislocation without evidence of

head injury.

• May also be used for other pain management, if ordered by Medical Control and if other pain management

techniques are insufficient.

ALL LEVELS

1. Routine medical care. If pain is secondary to a burn, see burn protocol (2.8).

2. Assure airway patency. Administer oxygen per protocol.

3. Apply pain relief measures such as splinting, positioning, ice packs, etc. as appropriate.

EMT STOP

EMT-I STOP

EMT-CC & P

4. Morphine 5 mg IM or Slow IV/IO (if SBP >100 mmHg) for pain >4/10 due to burns, amputation, or isolated extremity

fracture/dislocation without evidence of head injury. Medical control authorization is required for any other

indication, or any repeat doses.

Peds: Morphine 0.1 mg/kg (max 5 mg) IM,or Slow IV/IO if SBP normal for age and pain >4/10 due to burns,

amputation, or isolated extremity fracture/dislocation without evidence of head injury. Medical control

authorization is required for any other indication, or any repeat doses.

EMT-CC STOP

EMT-P STOP

ABSOLUTE ONLINE

5. If pain persists and if BP > 100 mmHg systolic and RR >8:

Morphine 0.1 mg/kg every 10 minutes IM or Slow IV/IO, per Medical Control

Peds: Morphine 0.1 mg/kg (max 5 mg per dose) every 10 minutes IM or Slow IV/IO, per Medical Control

PULMONARY EDEMA / CHF

CRITERIA

• Dyspnea/Tachypnea

• Rales/wheezing

• Pink, frothy sputum may be present or absent

ALL LEVELS

1. Routine medical care.

2. Assess signs, symptoms, hemodynamic status.

3. Position patient with head elevated (High Fowlers).

4. Initiate oxygen therapy.

5. If inadequate respirations or decreased level of consciousness, consider use of BVM.

6. Begin timely transport.

EMT STOP

EMT-I STOP

EMT-CC & P

7. If systolic BP > 90 mmHg:

Nitroglycerin 0.4 mg SL every 3-5 minutes as long as systolic BP > 90 mmHg

8. Consider CPAP if available

9. If patient has respiratory failure, altered mental status, or inadequate ventilations, consider intubation.

EMT-CC STOP

EMT-P PHYSICIAN CONSULT

10. If evidence of total body hypervolemia:

Furosemide (Lasix) 1 mg/kg (max 100 mg) slow IV/IO

11. If systolic BP < 90 mmHg:

Dopamine HCl (Intropin) 5 mcg/kg/min to maximum 10 mcg/kg/min IV/IO titrated to maintain systolic

BP >90 mmHg using a rate-limiting device.

My time is done... That's my $0.02

[Guest alsfirefighter]

I've had some fairly good success with Morphine when I can get the right dosage. I've gotten a few good laughs on the other end of the phone when I've asked for a 1/4 grain of MS for patients in severe pain or larger patients. I've also had the opposite end of the spectrum where you ask for one dose and get an order for 4 mg to be given 2mg at a time.

[NWFDMedic 58]

Well, one thing I've learned in EMS is not to trust studies. Look at what they did with Lidocaine. They told us it didn't work, when we've all seen it work, and then all of a sudden it came back because another study was done and it was shown in some cases it's actually better than other "more expensive" drugs. I've had some success with Morphine, but I'm willing to listen to the studies regarding chest pain, but not react too quickly about it, as it's still the standard of care.

As far as CPAP is concerned... what an awesome tool to have prehospitally. I've used it a couple of times since we got it here at MLSS and the patient turnarounds are outstanding. I didn't carry enough oxygen, nitro, lasix and morphine to do the trick that this simple little mask does. It stinks because my intubations are going down, but it's definitely improving patient outcomes, and that's what it's all about.

[WAS967 97]

It is in the proposed protocols for Westchester for us to give MS on standing order at a starting dose of 0.1 mg/kg I think it was. Will be a nice change if it goes through. Tho I would much prefer to see something like Fentanyl or Dilaudid used. Morphine is going the way of the dodo and Nitrous.

[Guest paramedico987]

Morphine works just fine... but you've got to get the right dose. I'm begining to learn which doctors to call when my patient needs a good 10.

I was told that a lot of docs won't give the order cuz they're worried about respiratory impairment, but that sounds like a cop-out to me since we all carry narcan and advanced ariway stuff.

I'd be a bit more nervous carrying such strong drugs as dilaudid... more likely to get shanked by a junkie looking to score!

If 20 of MS [all that I carry] isn't going to do it for you, then you're getting put under... the surgeon can worry about his consent form later.

[WAS967 97]

Seth must have read the same JEMS article that I just finished reading (from the June 2008 issue if people are interested).

Basically we can all thank REMO of Albany for stepping up to the plate and getting Morphine added to the list of controlled substances that EMS providers can administer on standing order in NYS. They have also added Fentanyl to the formulary but it sounds like they need to get orders to administer that. The article cites the advantages of Fentanyl for use in Abdominal pain and Multi-system Trauma. But they key here is they have paved the way for other regions (like Westchester) to add Morphine to the list of drugs that can be given via standing order.

[ny10570 745]

FDNY Docs are looking to replace morphine with Phentanyl but others are weary of the potency and publicity surrounding abuse of Phentanyl. More changes coming January '09 so we'll see whats in store.